Evolving Primary Care Model

Episode Overview

Transcript:

Daniel J. Marino: Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. Since COVID and even prior to that, primary care has gone through quite a bit of of change, more so for this specialty than I think any of the other specialties. And there's been a number of drivers, I think of those, those changes in, in primary care, some of which have been the rising cost of health care. I think a big one has been the undersupply of primary care physicians where they're looking to incorporate virtual health, um, other technologies, incorporating wearables, and so forth into the primary care model. So it's really forced us to rethink how we want to deliver primary care. Well, I am very pleased today to be joined by Dr. Michael Hanak. Dr. Hanak is a board-certified family physician working with a large academic medical center in the Chicago metropolitan area. Dr. Hanal has been instrumental in advancing his family practice and really the primary care group initiatives around the new primary, a new care delivery models utilizing digital health. Technology's been very instrumental in implementing their emr, as well as incorporating a lot of aspects around quality. Dr. Hanak, welcome to the program.

Dr. Michael Hanak: Thanks for having me. Appreciate being here.

Daniel J. Marino: So, Dr. Hanak, given that you've worked in the Chicago metropolitan area, I'm sure you have a very busy primary care practice. What are some of the changes that you've seen over the last few years that has really affected the way that you're delivering primary care to your patients?

Dr. Michael Hanak: Yeah, especially coming out of the pandemic, you know that's really altered a lot of things, you know, operations, workflows, even just staffing. I think that the emphasis you're seeing now is around value based care and kind of moving upstream. Whereas I think in the past, primary care was always seen as a front door and kind of a first step toward sick care, and now there's a real emphasis on how do we drive down cost. Doing that means you gotta even come in when you're healthy and, and what are the preventive steps we can be taken to, to drive cost before those things even occur? So that's a big transition over the last few years is really thinking more about value in the care model and also defining what quality means, you know, not just the process, but also the outcome.

Daniel J. Marino: In your practice, have you seen a big shift towards more, what I would call convenience-based primary care, where you've incorporated, say, virtual health or maybe patients want more on demand primary care services. Have you seen a lot of those changes within your own practice?

Dr. Michael Hanak: Yeah, absolutely. A lot of that is, is really coming off. Again, the pandemic, you know, that kind of pushed a lot of health systems to, to figure out a way to deliver those services remotely and offer more remotely, whether that be from the technology itself to the platform, to the types of care you can, you can get in-person versus in other ways. And I think that has evolved even further to what you had mentioned, the actual on-demand visit within a certain period of time from any location. Also an expanded set of services is being offered in that, in that way. Whereas during the pandemic, we had periods of visits that were offered in blocks. Your whole morning was gonna be offered remotely. Right now it's just mixed in the day. So you could see all of these patients in different ways throughout your day.

Daniel J. Marino: Yeah. That's interesting. And I'll tell you, it's, it's been the demands of patients. Primary care needs have really evolved post-pandemic. No doubt about that. But I also think that the shortage of primary care physicians has also contributed to us having to deliver primary care differently. I was reading an article not too long ago that 40% of primary care in certain rural markets are being delivered by advanced practice providers. How have you seen just within your own group a challenge with maybe a shortage of primary care physicians or having to change the model to support?

Dr. Michael Hanak: Yes. The team based models of care are kind of what this next phase is gonna look like. I think everyone is not necessarily struggling, but everyone is working to understand how best to deliver that and which areas, which services, are gonna be offered by KPPs, by pharmacists, by nurses in the office. We're expanding a lot of our services to now do nurse visits that are really at the top of their scope of licensure. Then also pharmacy-led visits where we have diabetes and hypertensive checks being done by nurses and pharmacists, all kind of under the oversight of a clinician of a physician. And that's allowed us to expand the number of patients that we're able to serve, while also kind of taking a little bit off the plate of the physician because there's only so many visits in the day. If you're in a shortage area, which even in metropolitan areas, we are short primary care physicians. You have to rely on that team. You have to develop a model that really serves a, a large group of people.

Daniel J. Marino: Well, I'll tell you, I love the team-based model of primary care, and I think if it's done well, you really can provide the services to really where the patient is based on their needs. But I think the most important thing that I've been able to see is care continues beyond the walls of the clinic, right? You're able to provide a level of outreach to patients, really respond to their needs, and so forth. When you've been able to develop the team-based model of care, what have been a couple of the real attributes that you've seen that have been important to really launch a good team-based model?

Dr. Michael Hanak: A big part of this is setting expectations with patients so that the expectation is not that you will see this one person for everything every time. I think most patients, particularly our younger demographic, are okay with that. The other thing is making sure that there's some level of continuity. So if you're gonna offer these extender visits, if you're gonna offer other services remotely, you have to be able to interface with the patient in an effective way that's efficient. They know how to use, you know, passwords and logins are one of the biggest challenges we actually face to delivering this model of care because we want to make these things accessible to all, but we also have, of course, regulatory standards to abide by. And so getting the patient connected with us is, is one of the big challenges. But once you establish that connection, you can swap in and out different members of the care team to be able to interface with the patient throughout their journey. And as you mentioned, the what happens between the visits is becoming more and more what health care is than, than the visit itself. The visit itself is setting the agenda and, and setting that guidance, but then you've gotta have this plan between visits that's efficient and patient centric. That's where health care is moving.

Daniel J. Marino: Well, it allows you to be more proactive with the primary care that you're delivering to patients. How much of that is dependent on having the data understanding the risk levels of your patients or beginning to understand and ensuring that they are going to their follow up visits. How, how important is that to the team based model?

Dr. Michael Hanak: That ties in both the team based model as well as just value based care in general. Even a lot of the vendors and offerings that are out there to offer analytics, it's important that you figure out that next best action that the data coming through is both actionable and impactable for the patient. I think that a lot of these tools can generate a lot of data, but then, in the course of your workday, you're not gonna be able to have that time to sit down and sort through it all. So that's partly on the team and you rely on your team to sort through some of the data and figure out. These are the most important pieces we need to take an action on. Then another part of it is on the tools that you've implemented through, whether it's through your EHR or through another vendor. Using those two things together to really make the most of your team based delivery, I think is, that's kind of the magic, the magic sauce here. If we can get that going really well and you have a, a way to outreach to patients between those visits so that stay engaged, that's really how we're gonna deliver better care through the use of, of these various technologies.

Daniel J. Marino: Well, and I'll tell you, that's where value-based reimbursement and value-based contracting really support the team-based model because you're working on behalf of the outcomes of the patient and the population. You're working as a team, um, as opposed to in a fee-for-service structure. You're not as focused on us. However, creating that balance a challenge that many hospitals, many health systems, and many primary care providers have struggled with.

Dr. Michael Hanak: Yeah. Capturing risk is difficult if you haven't met a patient or a group of people who have never seen you before, they sign onto a plan and they haven't come in. So you're not really certain what's out there that, that needs to be addressed. That's part of this work too is doing really good outreach and navigation. We rely on our tools heavily to get good navigation out to patients so they feel supported when they're approaching, you know, the large doors of a large health system. But then the other part is when we do see them, whether it's at initial visit or routine wellness visit, to really document and capture all of that complexity that makes up that patient, because then that's gonna go into our algorithms to risk adjust and prioritize, uh, knowing, no, maybe not who's in that 1%, but who's in the rising risk, who's in that 20% at the top that we need to see with some regularity, knowing that these conditions, if they escalate, will become those cost drivers.

That's a big part of what we rely on our technology for. And it's where we're gonna put more of those resources of our team around. Also, I shouldn't say deprioritize, but you're gonna take that the 60, 70, 80% and we're gonna say, listen, these visits and these care that you may need on demand, it's totally appropriate for a pharmacist to help out with under this level of oversight. You've gotta have physician-led, team-based care, and that's how you're able to accomplish these goals and risk adjust and make sure you're caring for the whole population at a reasonable cost and a high level of quality

Daniel J. Marino: If you're just tuning in. I'm Daniel Marino, you're listening to Value-Based Care Insights. I'm talking today with Dr. Michael Hanak about the evolving primary care model. So Dr. Hanak, with these non-traditional competitors, how do you see that affecting primary care and even your practice now or down the road?

Dr. Michael Hanak: I think in a lot of ways, number one, I would say that these, these large non-traditional settings, the growth of these entities demonstrates that patients are interested in a new model of care. They want convenience, they want home delivery, and they want lower costs. You know, the out-of-pocket costs for many of these services are different than the traditional insurance-based care. So I think that should be sending a message to all of us, not just on the clinician side, but on the payer side, that there is a strong interest in a new model of care. The other thing that I think it does is it does drive those traditional models to change. There's gonna have to be evolution to allow for more tools, more technology, easier access, easier navigation. People are moving away from the one-stop kind of central point of entry where maybe a health system has multiple points of entry depending on the need, depending on what the patient has going on.

We have to be able to adapt to that and, and make it convenient for patients because otherwise it's easy now to move to other structures to find these other resources. I think it's definitely driving change. On the other hand, and I'm not saying that that's all bad because most of those changes are positive. But it does also in a way, deprioritize, it devalues the importance of having a coordinator of your care, a coordinator of your health. I see that as obviously as a primary care physician. Um, people that are maybe more complex than those systems can manage. They come to me with more problems because the system wasn't prepared to, to handle, those cases. I think we have to find that hybrid where you can have the central support when you're in that risk category, that that mandates it, but also be able to offer these other things when things are going well. And you just need a hand between your visits.

Daniel J. Marino: Right. And I think as we think about the evolving primary care model, education to patients is going to be critical. Convenience-based primary care, incorporates more consumerism around the delivery of primary care. That's what patients want, right? We're all busy in our lives and, and I think there's a strong place to that, but it does not take the place of a strong primary care physician-patient relationship. And one of the things that I often see, you know, we've had the opportunity to do numerous primary care strategies through Lumina Health Partners. And what always comes out of that is that many health systems and many medical groups had developed their primary care model because it's been convenient to them, right? So you've had set office hours from eight to five, maybe two or three Saturdays a month, not really too many extended hours.

Well, that's not really what patients want. So if we're going to compete, we have to change, we have to go through a paradigm shift of changing our thinking, incorporating convenience-based primary care as, as you've mentioned, otherwise, you run the risk of losing these patients to what I often call the invisible competitor, right? You don't know they're gone until it's almost too late. How do you educate your patients, or how have you educated your patients to maintain that relationship, not only with you but with your team to ensure that they're still connected and still able to provide that support when you need to?

Dr. Michael Hanak: Yeah, we spend a lot of time on even those initial visits on explaining and, and demonstrating all of the offerings that we have. Because I think most of the patients that come and see me, are accustomed to the traditional model. I mean, you know, we're in a large academic center that is kind of the traditional model, and we have to kind of demonstrate, hey, we have these other ways of delivering care just like you see at CVS or Walgreens or other places, and it offers the extended hours. We have an on-call service, and these are the tools you can use. We show the patient portal. We talk about some of the tools we have on our analytics side, why it's important to gather their information, and spend a lot of time collecting data up front to hopefully use that to better serve them in the future.

So we're pretty transparent about that. And it does require some adaptation, some of these patients are just not prepared for these tools to use them to use their mobile devices. We get people set up in the office. We use iPads in the office to collect information from people. So there's a little bit of a learning curve, but I think at the end, it, it ends up better serving the patient I think we're looking at this shortage thinking, I think society looks at the shortage thinking, well, you know, not much can be done about this. People have left health care, and they've had a lot of stressors. I do think that there's a, a place here to talk more about, and that's maybe a future session, but to talk more about the investment in these services so that we can have people in the pipeline choosing primary care because we have a model that's well supported, right? Instead of kind of the, you know, grasping here and there to, to find those resources to create the team that doesn't even always have that ROI to it. I think with value-based care, we're seeing more of that than certainly, we did with fee for service, but this is part of that evolution that I think we're gonna see. There needs to be an investment in this to make this really work and also to drive down our costs.

Daniel J. Marino: Yeah, I agree with you. And I think it also it provides stronger care to the patient because it's helping them get used to some of this technology and helping them understand how maybe primary care can or has to evolve in technology with the new model, how do you see care management changing you? You mentioned a little bit that there's a lot more outreach to patients and it's a little bit different, and obviously having the care managers work with the care teams is important. Where do you see care management coming into play in supporting the new primary care models?

Dr. Michael Hanak: Well, certainly care management has always been involved in those transitions. When people are leaving a health care setting, leaving the hospital or acute rehab, care management is your kind of the first point of contact to make sure the patient has what they need and identify any additional needs that the health care team can facilitate. So that's always been their strength and where they have been most important to a system. I think we're now moving to a place where it doesn't necessarily always have to be a care manager, but even just a patient navigator, right? A community health worker, you know, we're looking to, to move the care into the communities. And the way we do that is by having outreach from community health workers that don't necessarily rise to the level of nursing care or licensed social work, but can just do the check in the navigation and the facilitation back when those needs, uh, you know, present themselves. That's been a shift for us. Everything can't just go to a licensed care manager when we have lots of patients who just need a phone call, right? Right. And that's a text outreach and a connection with an appointment. So when the platform can't deliver the technology barriers that patients may have, we look to our navigators to do that. And that's been a big change in how we've managed our team.

Daniel J. Marino: That's a natural evolution because not only then you, you need to have your care managers to handle more of the acute primary care services, maybe handling a lot of the chronic diseases and so forth. But you've got all of this social determinant activity going on with the patients and, and frankly, just having a nonclinical navigating partner there performing that outreach, one sort of closes that information gap, but two, I would assume as the primary care physician, that becomes invaluable for you to, to get a better frame of the whole picture, right? So you really begin to understand not only what's happening with the patient from a clinical standpoint, but from a non-clinical standpoint, those things that are really influencing those issues with the patient. I would think that would be invaluable.

Dr. Michael Hanak: Yeah, absolutely. We are doing our best to offer to screen for these social needs, but I will tell you that in the community with community health workers or navigation support, that's really where the screening is most effective. We do our best to screen patients, presenting here for primary care services. Then the other thing is that I think a lot of smaller practices are gonna struggle with the intervention right screen, how can I offer services that are needed that ultimately do impact the patient's health? Again, that's where we look to, I think payers, you know, Medicare to say, what, what are the structures we need to implement the framework for being able to deliver this more broadly? Yeah, I would say even, even our large entities like the Walgreens and the cvs, they're gonna come across the same needs, and if they start screening, they'll have the same kind of challenges, uh, which is one of those deficits. We don't think about the disparities in these populations that we're serving, and that's really important from a health equity standpoint. So a big part of what we do at our, at our institution.

Daniel J. Marino: Well, there's no doubt that I think these partnership models are going to have to really evolve to, to satisfy the, certainly the primary care needs of the patients. and, I'm a big proponent of team-based care, and I think even across multiple partnerships, that becomes invaluable. Dr. Hanak, this has been fantastic. I really appreciate it. Primary care is one of the areas that's near and dear to my heart. I've done a lot of research on it, and have helped many organizations evolve their strategies. Any final words of advice or thoughts that you might wanna share with our listeners?

Dr. Michael Hanak: I'd encourage everyone who is interested in these models, or maybe changing the model for, for your practices to consider looking at the National Association of ACOs. They have a great set of lecture topics and presentations. health care Value Week is, is coming up in January. There are some great topics and content tied to that. And that's a great way to initiate this conversation and, and start to communicate, you know, with your patients and your peers.

Daniel J. Marino: Yeah, great point, great point. Well, I wanna thank you again, for spending a little time today with us going through the evolving primary care model. I would love to have you back again, and talk about maybe social determinants and the role that they plays as well as some of the investments that are required as we continue to advance primary care. As I mentioned, this is an area that I feel is extremely important to our health care setting. So thanks again, Dr. Hanak. Really appreciate it.

Dr. Michael Hanak: Thank you. Take care.

Daniel J. Marino: I wanna thank everyone for listening today Until the next insight. I am your host, Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners